Gen Nakanishi

A randomized double-blind trial of intravenous immunoglobulin for bullous pemphigoid.

BACKGROUND Patients with steroid-resistant bullous pemphigoid (BP) require an appropriate treatment option. OBJECTIVE A multicenter, randomized, placebo-controlled, double-blind trial was conducted to investigate the therapeutic effect of high-dose intravenous immunoglobulin (IVIG; 400mg/kg/day for 5days) in BP patients who showed no symptomatic improvement with prednisolone (≥0.4mg/kg/day) administered. METHODS We evaluated the efficacy using the disease activity score on day15 (DAS15) as a primary endpoint, and changes in the DAS over time, the anti-BP180 antibody titer, and safety for a period of 57days as secondary endpoints. RESULTS We enrolled 56 patients in this study. The DAS15 was 12.5 points lower in the IVIG group than in the placebo group (p=0.089). The mean DAS of the IVIG group was constantly lower than that of the placebo group throughout the course of observation, and a post hoc analysis of covariance revealed a significant difference (p=0.041). Furthermore, when analyzed only in severe cases (DAS≥40), the DAS15 differed significantly (p=0.046). The anti-BP180 antibody titers showed no difference between the two groups. CONCLUSION IVIG provides a beneficial therapeutic outcome for patients with BP who are resistant to steroid therapy.

A novel homozygous mutation of the EVER1/TMC6 gene in a Japanese patient with epidermodysplasia verruciformis.

Epidermodysplasia verruciformis (EV; OMIM 226400) is a rare, autosomal recessive genetic disease characterized by abnormal susceptibility to disease-specific human papillomaviruses (HPVs). Patients with EV have usually presented with skin lesions resembling disseminated flat warts or pityriasis versicolor since childhood. Some of the lesions may progress to skin cancers late in life. Recently, genetic susceptibility loci for EV were mapped to chromosomes 2p21–24 and 17q25. Two different genes, EVER1 ⁄TMC6 and EVER2 ⁄ TMC8, were identified in chromosome 17q25. We report a woman with HPV type 12-induced EV who carried a homozygous CfiT transition at nucleotide position 220 within exon 4 of EVER1 that led to a premature translation termination.

Dendritic cell subsets and immunological milieu in inflammatory human papilloma virus-related skin lesions

BACKGROUND Human papilloma virus (HPV)-related warts persist, evading host immune surveillance, but sometimes disappear with inflammation. OBJECTIVES To elucidate the immune evasion mechanisms of HPV, we have examined the density, dynamics, and subsets of dendritic cell (DC) types in non-inflammatory or inflammatory HPV-related skin lesions such as warts and Bowens disease (HPV-Bowen), and compared the epidermal expression levels of macrophage inflammatory protein (MIP)-3α and E-cadherin. METHODS The expression of various DC markers, MIP-3α, and E-cadherin in the tissue samples obtained from patients with warts, HPV-Bowen and HPV-unrelated skin diseases was evaluated by immunohistochemistry. MIP-3α gene expression levels were examined in warts and HPV-Bowen by in situ hybridization (ISH) and real-time quantitative polymerase chain reaction (RT-qPCR). RESULTS The numbers of Langerhans cells (LCs) and the expression levels of MIP-3α and E-cadherin were decreased in non-inflammatory warts and HPV-Bowen, as compared with normal skin. Both epidermal LCs and MIP-3α expression reappeared in inflammatory warts, associated with dermal infiltrates composed of many cytotoxic T cells and various subsets of DCs, while cellular infiltrates in HPV-Bowen contained many B cells and plasma cells with sparse infiltration of DCs. The upregulation of MIP-3α gene expression was confirmed in the inflammatory warts and HPV-Bowen by ISH and RT-qPCR. CONCLUSIONS The depletion of LCs in the non-inflammatory warts and HPV-Bowen is associated with a down-regulation of expression levels of MIP-3α and E-cadherin in the lesional keratinocytes. MIP-3α expression is upregulated in lesional keratinocytes of inflammatory warts, with the subsequent recruitment of various DC subsets and cytotoxic T cells, whereas plasma cell-rich infiltration was induced in HPV-Bowen.

Erosive pustular dermatosis of the scalp-like eruption due to gefitinib: case report and review of the literature of alopecia associated with EGFR inhibitors.

A 69-year-old Japanese woman with multiple brain metastases secondary to non-small-cell lung cancer was treated with radiosurgery, and subsequently started oral gefitinib. Three years later, she presented with erythematous erosive alopecia with pustules on the scalp. A biopsy specimen showed a dense perifollicular infiltration composed of lymphocytes, neutrophils and abundant plasma cells. Methicillin-resistant Staphylococcus aureus was cultured from the lesions; however, treatment with antibiotics was not effective. We diagnosed an eruption resembling erosive pustular dermatosis of the scalp. Although oral steroids did not improve the lesions, the pustules and erythema of the scalp rapidly improved within a few weeks after discontinuation of gefitinib. There have been only 11 case reports of alopecia associated with epidermal growth factor receptor (EGFR) inhibitors including our case. It is noteworthy that all cases were female, and most cases involved the parietal scalp. Moreover, the reduction or discontinuation of the EGFR inhibitors was needed in all cases with erythematous alopecia, which remained as scarring alopecia.

Ichthyosiform eruptions in association with primary cutaneous T-cell lymphomas

Background  Malignant lymphoma is occasionally complicated by ichthyosiform eruptions.

Linear IgA disease with IgA antibodies directed against 200‐ and 280‐kDa epidermal antigens

We report an 80‐year‐old man with the lamina lucida type of linear IgA disease, with IgA autoantibodies reactive with 200‐kDa and 280‐kDa epidermal proteins. The patient presented with widespread bullous lesions on his trunk and extremities without mucosal involvement. Histopathology of lesional skin showed a subepidermal blister with papillary microabscesses of neutrophils and a few eosinophils. Direct immunofluorescence microscopy of perilesional skin showed linear deposits of IgA and C3 at the basement membrane zone. The patient’s serum contained IgA autoantibodies that bound exclusively to the epidermal side of 1 mol L−1 NaCl split skin as determined by indirect immunofluorescence microscopy. Circulating IgA autoantibodies to 200‐ and 280‐kDa antigens were detected in the patient’s serum by immunoblot analysis using extracts from normal human epidermis and human epidermal keratinocytes. These two antibodies, eluted from individual nitrocellulose membranes, reacted with the epidermal side of 1 mol L−1 NaCl split skin on indirect immunofluorescence microscopy, and bound to hemidesmosomes as determined by immunoperoxidase electron microscopy. This observation suggests the presence of hitherto uncharacterized 200‐ and 280‐kDa hemidesmosomal proteins distinct from BPAG1, BPAG2 and β4 integrin as target antigens in linear IgA disease.

Human papillomavirus genome integration in multifocal vulvar Bowen’s disease and squamous cell carcinoma

Human papillomavirus (HPV) is an important aetiological agent in cervical carcinomas and in malignant skin tumours. Integration of the HPV DNA into host genome is one of the most important risk factors for malignant transformation. We report a patient with multiple black plaques and an erythematous nodule on her vulva. On histological examination, multifocal vulvar Bowen’s disease (BD) and invasive squamous cell carcinoma (SCC) were found. An amplification of papillomavirus oncogene transcripts (APOT) assay showed that two locations of BD had only episome‐derived HPV16 transcripts, but the other two sites of BD and the nodule of invasive SCC had HPV16 transcripts derived from integration. Sequencing analysis revealed that the invasive SCC had its integration site at 8q24, the Myc locus. Our results suggest that the APOT assay in multiple sites of the same patient may be a valuable tool for evaluation of the clinical degree of malignancy for vulvar BD.

Hyperkeratotic variant of porokeratosis Mibelli with dermal amyloid deposits

We report a case of hyperkeratotic variant of porokeratosis Mibelli with dermal amyloid deposits. A 66‐year‐old man presented with multiple brownish keratotic lesions on the lower extremities, a verrucous nodule on the third toe of the left foot and brownish verrucous plaques on the buttocks for several years. Histopathological examination of the hyperkeratotic plaque in the right gluteal region revealed extreme hyperkeratosis and cornoid lamella. In the papillary dermis, there were prominent eosinophilic amorphous materials which were positive to Dylon staining. Treatment with oral etretinate resulted in a remission of the skin lesions in this case.

Expression of double-stranded RNA-activated protein kinase in keratinocytes and keratinocytic neoplasia.

Double‐stranded RNA‐activated protein kinase (PKR) is a interferon‐induced protein initially known for its inhibitory effects on cellular and viral protein synthesis. In recent studies, PKR has been shown to be an important participant in a broad array of cellular processes, including signal transduction, differentiation, apoptosis, cell growth, and tumorigenesis. The expression of PKR in normal human keratinocytes (NHEK) was examined, and its expression in several skin lesions was compared immunohistochemically with that of proliferating cell nuclear antigen (PCNA). Expression of PKR mRNA was detected in NHEK without IFNγ treatment; the level of PKR mRNA increased with IFNγ treatment for two hours. Immunoblot analysis revealed that the monoclonal anti‐PKR antibody reacted specifically with a 68kDa PKR protein in extracts from NHEK. Immunohistochemistry revealed that PKR protein was expressed in normal epidermis and mucosa. PKR expression was not restricted only to suprabasal cells but was also observed in basal cells positive for PCNA. In psoriatic plaques, PKR expression was lower in basal and parabasal keratinocytes and comparable in suprabasal keratinocytes to the levels in normal skin. PKR was partially detected in atypical cells in non‐invasive keratinocytic neoplasia but was completely absent from undifferentiated tumor cells of squamous cell carcinoma. The present study demonstrated that PKR protein is constitutively expressed in epidermal and epithelial keratinocytes of normal skin and mucosa and indicated that a loss of PKR is not associated with the malignant transformation itself but with the increased cell proliferative activity and the altered differentiation of keratinocytes.

IRF-1 expression in normal human epidermal keratinocytes

Interferon gamma (IFN-γ) is a potent inducer of cell growth arrest in human epidermal keratinocytes. Interferon regulatory factor-1 (IRF-1), an interferon-inducible gene, is a mediator of interferon action. It has also been suggested that IRF-1 may have a functional role as a tumor suppressor gene and may be associated with the antiproliferative effect of IFN-γ. We examined the expression of IRF-1 mRNA in normal human epidermal keratinocytes (NHEK). Northern blot analysis demonstrated an increased expression of IRF-1 mRNA by IFN-γ in NHEKs. This increased expression of IRF-1 mRNA by IFN-γ was not blocked by treatment with cycloheximide, but was abolished by treatment with actinomycin D. In addition, neither pretreatment with TPA, a protein kinase C (PKC) activator, nor treatment with H7, a PKC inhibitor, affected the induction of IRF-1 mRNA by IFN-γ. These results indicate that IFN-γ-induced IRF-1 mRNA in NHEKs is transcriptional and PKC-independent.